Foot → ankle → leg → knee → thigh → hip
Foot
28 bones (Calcanues, Talus, Navicular, Cuneiform x3, Cuboid, Metatarsals x5, Phalanges x14, Sesamoid x2)
Multiple articulations
Medial Longitudinal Arch (mobility) – Calcaneus, Talus, Navicular, All Cuneiforms, MT’s 1-3
Lateral Longitudinal Arch (stability) – Calcaneus, Cuboid, MT’s 4&5
Transverse Arches – Tarsal arch, Proximal MT arch (heads of Mets) and distal MT arch (bases of Mets)
Functions – Wt. bearing & force transference = ½ to forefoot ½ to hind foot. Forefoot – 2/6 to 1st Met. 1/6 to remaining 4 Mets.
Locomotion = Adapting to pitch, roll and yaw of various surfaces from below and rotation from lower limb and body from above. Also helps direct ground reaction forces.
Myotomes –
Subtalar Inversion = L4,5
Subtalar Eversion = L5,S1
Ankle Dorsiflexion = L4,5
Ankle Plantarflexion = S1,2
MTP & P Dorsiflexion = L5,S1
MTP & P Plantarflexion = S1,2
Cutaneous supply – 1. Saphenous N (L3,4 branch from Femoral) Medial malleouls and medial arch. 2. Superfical Fibular N (L4-S1) dorsum of foot (except between 1st & 2nd toe and 5th toe). 3. Deep Fibular N (L5) between 1ts & 2nd toes. 4. Med. Plantar N (L4,5) Dorsum of foot, ant to calcaneus toes 1-4, not lat. border of med. Arch. 5. Lat. Plantar N (S1,2) plantar surface of 5th toe & ant-lat side of foot. 6. Sural N (S1,2) Postero-lateral plantar surface & 5th toe on dorsal surface, lat. Border up to lat. Malleolus. 7. Calcaneal N (S1,2) plantar surface of calcaneus.
Ankle
Talo crural joint. Articulation between trochlear surface of Talus and distal ends of Tibia (medial – bears more weight than lateral) and Fibula (lateral). Synovial hinge joint.
Stabilised medially by Deltoid ligament –
Superficial bands = Tibionavicular (Ant.), Tibiocalcaneal (Mid) & Post. Tibiotalar (Post.)
Deep Band = Ant. Tibiotalar
Stabilised laterally by – ATFL, PTFL and CFL
Nerve supply to joint = Tibial, Deep & Superficial Fibular and Sural nerves.
Medial side more stable than lateral due to length of Tibia and stronger ligamentous arrangement.
Muscular control and stability of the ankle provided by:
Muscles of the Leg
1. Anterior Compartment = Tib. Ant. (upper 2/3 lat. Tibia to medial cuneiform and 1st Met).
EHL (mid 2/4 Ant. Fib and IOM to base distal phalanx)
EDL (Lat. Tibial condyle, upper ¾ of Ant. Fib and IOM to mid and proximal phalanges)
Fibularis Tertius (lower 1/3 Ant. Fib. & IOM to dorsal surface base of 5th Met.)
Deep Fibular Nerve L4-5 (from Common Fibular L4-S2)
Cutaneous Supply = Spahenous L3-4 (Med), Superficial Fibular L4-S1 (distal Lat.) and Common Fibular (L4-S2)
Anterior Tibial Artery
Superfical Fibular Nerve L4-S1 (from Common Fibular L4-S2)
Cutaneous Supply = Common Fibular (L4-S2)
Anterior Tibial Artery & Fibular Artery
FDL (Post. surface of body of Tib. to bases of distal phalange of toes 1-4)
Tib. Post. (Inner post. surfaces of Tib & Fib + IOM to bases of Mets 2-4, all cuneiforms, cuboid & navicular)
Superficial – Gastrocs., (Med & Lat. femoral condyles to Calcaneus via tendocalcaneal)
Soleus (Fib and med border of Tib. soleal line to Calcaneus via tendocalcaneal)
Plantaris (lateral supracondylar ridge of femur to Calcaneus vis tendocalcaneal).
Tibial Nerve (L4-S3)
Cutaneous Supply = Spahenous L3-4 (Med.) & Sural (S1-2)
Posterior Tibial Artery
Knee
Tibiofemoral joint and Patellofemoral joint.
Generally considered to be a synovial hinge joint.
Extra-capsular articulation of Superior Tibiofibular joint (plane joint)
Nerve Supply – Ant. = Femoral (L2-4), Common Fibular (L4-S2) & Spahenous (L2-3)
Post. = Tibial (L4-S3) and Obturator (L2-4)
Ligaments
Cruciate ligaments are intra-capsular but extra-synovial.
ACL = Lateral femoral condyle to anterior intercondylar area on Tibia (close to Ant horn of Medial meniscus)
Limits anterior translation and medial rotation of tibia relative to Femur, taught in extension.
PCL = Medial femoral condyle to posterior intercondylar area on Tibia.
Limits posterior translation of Tibia in relation to the Femur, taught in extension.
Transverse Ligament = Medial to lateral meniscus, anterior to menisci.
Coronary Ligaments = Attach inferior edges of menisci to tibial plateaus.
MCL = Medial Femoral epicondyle (distal to Adductor tubercle) to medial Tibial condyle (attached to medial meniscus. Distal attachment partially covered by pes anserinus) Broad and flat.
Limits medial gapping and resists valgus forces
LCL = Lateral Femoral epicondyle to Fibular head.
Limits lateral gapping a resists varus forces. Separate from capsule and lateral meniscus.
Menisci (shock absorbers, reduce friction, dissipate forces)
Medial = C-shaped fibrocartilaginous structure. Ant. End attached to ant. Intercondylar fossa on Tibia plateau, in front of attachment of ACL. Post. end attaches to post. intercondylar fossa between attachments of lat. meniscus and PCL.
Wider posteriorly than anteriorly, fused with MCL, relatively immobile compared to lateral. Most displacement occurs with external rotation of Tibia.
Lateral = O-shaped. Anteriorly it is attached to the intercondylar eminence, lat. to & behind the ACL (blends). Posteriorly attached to intercondylar eminence, in front of post. part of Med. Grooved laterally for Popliteus which separates it from LCL.
Foot
28 bones (Calcanues, Talus, Navicular, Cuneiform x3, Cuboid, Metatarsals x5, Phalanges x14, Sesamoid x2)
Multiple articulations
Medial Longitudinal Arch (mobility) – Calcaneus, Talus, Navicular, All Cuneiforms, MT’s 1-3
Lateral Longitudinal Arch (stability) – Calcaneus, Cuboid, MT’s 4&5
Transverse Arches – Tarsal arch, Proximal MT arch (heads of Mets) and distal MT arch (bases of Mets)
Functions – Wt. bearing & force transference = ½ to forefoot ½ to hind foot. Forefoot – 2/6 to 1st Met. 1/6 to remaining 4 Mets.
Locomotion = Adapting to pitch, roll and yaw of various surfaces from below and rotation from lower limb and body from above. Also helps direct ground reaction forces.
Myotomes –
Subtalar Inversion = L4,5
Subtalar Eversion = L5,S1
Ankle Dorsiflexion = L4,5
Ankle Plantarflexion = S1,2
MTP & P Dorsiflexion = L5,S1
MTP & P Plantarflexion = S1,2
Cutaneous supply – 1. Saphenous N (L3,4 branch from Femoral) Medial malleouls and medial arch. 2. Superfical Fibular N (L4-S1) dorsum of foot (except between 1st & 2nd toe and 5th toe). 3. Deep Fibular N (L5) between 1ts & 2nd toes. 4. Med. Plantar N (L4,5) Dorsum of foot, ant to calcaneus toes 1-4, not lat. border of med. Arch. 5. Lat. Plantar N (S1,2) plantar surface of 5th toe & ant-lat side of foot. 6. Sural N (S1,2) Postero-lateral plantar surface & 5th toe on dorsal surface, lat. Border up to lat. Malleolus. 7. Calcaneal N (S1,2) plantar surface of calcaneus.
Ankle
Talo crural joint. Articulation between trochlear surface of Talus and distal ends of Tibia (medial – bears more weight than lateral) and Fibula (lateral). Synovial hinge joint.
Stabilised medially by Deltoid ligament –
Superficial bands = Tibionavicular (Ant.), Tibiocalcaneal (Mid) & Post. Tibiotalar (Post.)
Deep Band = Ant. Tibiotalar
Stabilised laterally by – ATFL, PTFL and CFL
Nerve supply to joint = Tibial, Deep & Superficial Fibular and Sural nerves.
Medial side more stable than lateral due to length of Tibia and stronger ligamentous arrangement.
Muscular control and stability of the ankle provided by:
Muscles of the Leg
1. Anterior Compartment = Tib. Ant. (upper 2/3 lat. Tibia to medial cuneiform and 1st Met).
EHL (mid 2/4 Ant. Fib and IOM to base distal phalanx)
EDL (Lat. Tibial condyle, upper ¾ of Ant. Fib and IOM to mid and proximal phalanges)
Fibularis Tertius (lower 1/3 Ant. Fib. & IOM to dorsal surface base of 5th Met.)
Deep Fibular Nerve L4-5 (from Common Fibular L4-S2)
Cutaneous Supply = Spahenous L3-4 (Med), Superficial Fibular L4-S1 (distal Lat.) and Common Fibular (L4-S2)
Anterior Tibial Artery
- Lateral Compartment = Fibularis Longus (head and lateral surface of Fib to Med. Cuneiform & 1st met.)
Superfical Fibular Nerve L4-S1 (from Common Fibular L4-S2)
Cutaneous Supply = Common Fibular (L4-S2)
Anterior Tibial Artery & Fibular Artery
- Posterior Compartment = Deep – Popliteus (Lat. surface of Lat. Femoral condyle to post. surface of Tib, above Soleal line)
FDL (Post. surface of body of Tib. to bases of distal phalange of toes 1-4)
Tib. Post. (Inner post. surfaces of Tib & Fib + IOM to bases of Mets 2-4, all cuneiforms, cuboid & navicular)
Superficial – Gastrocs., (Med & Lat. femoral condyles to Calcaneus via tendocalcaneal)
Soleus (Fib and med border of Tib. soleal line to Calcaneus via tendocalcaneal)
Plantaris (lateral supracondylar ridge of femur to Calcaneus vis tendocalcaneal).
Tibial Nerve (L4-S3)
Cutaneous Supply = Spahenous L3-4 (Med.) & Sural (S1-2)
Posterior Tibial Artery
Knee
Tibiofemoral joint and Patellofemoral joint.
Generally considered to be a synovial hinge joint.
Extra-capsular articulation of Superior Tibiofibular joint (plane joint)
Nerve Supply – Ant. = Femoral (L2-4), Common Fibular (L4-S2) & Spahenous (L2-3)
Post. = Tibial (L4-S3) and Obturator (L2-4)
Ligaments
Cruciate ligaments are intra-capsular but extra-synovial.
ACL = Lateral femoral condyle to anterior intercondylar area on Tibia (close to Ant horn of Medial meniscus)
Limits anterior translation and medial rotation of tibia relative to Femur, taught in extension.
PCL = Medial femoral condyle to posterior intercondylar area on Tibia.
Limits posterior translation of Tibia in relation to the Femur, taught in extension.
Transverse Ligament = Medial to lateral meniscus, anterior to menisci.
Coronary Ligaments = Attach inferior edges of menisci to tibial plateaus.
MCL = Medial Femoral epicondyle (distal to Adductor tubercle) to medial Tibial condyle (attached to medial meniscus. Distal attachment partially covered by pes anserinus) Broad and flat.
Limits medial gapping and resists valgus forces
LCL = Lateral Femoral epicondyle to Fibular head.
Limits lateral gapping a resists varus forces. Separate from capsule and lateral meniscus.
Menisci (shock absorbers, reduce friction, dissipate forces)
Medial = C-shaped fibrocartilaginous structure. Ant. End attached to ant. Intercondylar fossa on Tibia plateau, in front of attachment of ACL. Post. end attaches to post. intercondylar fossa between attachments of lat. meniscus and PCL.
Wider posteriorly than anteriorly, fused with MCL, relatively immobile compared to lateral. Most displacement occurs with external rotation of Tibia.
Lateral = O-shaped. Anteriorly it is attached to the intercondylar eminence, lat. to & behind the ACL (blends). Posteriorly attached to intercondylar eminence, in front of post. part of Med. Grooved laterally for Popliteus which separates it from LCL.
Thigh Muscles
- Anterior Compartment = Sartorius (Inf. to ASIS to upper Ant-Med. surface of Tib. Pes Anserinus)
Rectus Femoris (AIIS & iliac posrtion of acetabulum to patellar tendon)
Vastus Lateralis (Great Trochanter, Inter-Trochanteric line & Linea Aspera to Patella and Tib. tuberosity patella ligament)
Vastus Intermedius (Upper 2/3 of anterolateral Femur to Patella and Tib via patella lig)
Vastus Medialis (Anteromedial femur from intertrochanteric line , pectineal line and med. lip of linea aspera to patella)
(Occ. Iliacus – Iliac crest, fossa ala of sacrum & ant. SI lig to lesser trochanter. Psoas – Bodies T12-L5, discs and TP’s to lesser trochanter)
Femoral Nerve L2-4 (Illiacus Femoral L2-4, Psoas Ventral Rami L1-3)
Cutaneous Supply = Ant. Femoral Cutaneous N L2-3 and Lat. femoral Cutaneous N. L2-3
Femoral Artery
- Medial Compartment = Gracilis (Ant. margin lower ½ of symphasis pubis to upper anteromedial Tib. pes anserinus)
Adductors Magnus (A-Ischiopubic ramus H-Ischial tuberosity to A-Gluteal tuberosity, linea aspera & Med. supracondylar line)
Longus (Body of pubis to mid. 1/3 of linea aspera)
Brevis (Body & inf. ramus of pubis to pectineal line & proximal linea aspera)
(occ. Obturator Externus – edge of obturator foramen & membrane to trochanteric fossa & Pectineus – Sup. Pubic ramus to Pectineal line, inf. to lesser trochanter).
Obturator Nerve L2-4 (Obturator Externus Obturator L2-4, Pectineus Femoral L2-3)
Cutaneous Supply = Anterior Femoral Cutaneous N L2-3
Obturator Artery
- Posterior Compartment = Biceps Femoris (LH-Ischial tuberosity SH-Linea aspera & Lat. supracondylar line to Lat. head of Fib) Semimembranosus (Ischial tuberosity to post. med. tib.)
Semiteninosus (Iscial tuberosity to ant. med. sup. Tib. Pes anserinus) .
Sciatic Nerve (Tibial Part) L4-S3
Cutaneous Supply = Post. Femoral Cutaneous N S1-3
Inferior Gluteal Artery, Profunda Femoris and perforating arteries.
Femoral Triangle
Boundaries
Sup. = Inguinal lig.
Med. = Add. Longus
Lat. = Sartorius
Floor = Add. Longus & Iliopsoas
Roof = Fascia Lata
Contents
Femoral Nerve
Femoral Sheath - Femoral Artery, vein & canal (lymph vessels)
Hip
Multi-axial synovial joint (ball and socket).
Nerve supply = Femoral, Obturator & Sup. Gluteal Nerves
Blood supply = Cruciate anastomosis – Obturator artery, med. and lat. circumflex femoral arteries, sup. And inf. gluteal arteries.
Blood supply to head of femur = Acetabular branches of obturator and medial circumflex femoral arteries, ligament of head of femur (branch from obturator), med. and lat. femoral circumflex arteries.
Ligaments
Iliofemoral – ‘Y’ shaped. Ant. ASIS & Acetabular margin to Intertrochanteric line. Limits extension, adduction and medial rotation.
Pubofemoral – Inferomedial. Pubic part of acetabulum and Sup. Pubic ramus to Intertrochanteric line. Limits abduction and external rotation.
Ischiofemoral – Post. Ischial part of acetabulum to sup. Intertrochanteric line and neck of femur. Limits extension and adduction. Thin and weak.
Muscles
Gluteus Maximus (Ilium, post. gluteal line, dorsal sacrum & coccyx & sacrotuberous lig. to ITB & gluteal tuberosity) Extends & laterally rotates thigh. Inferior gluteal N L5-S2.
Gluteus Medius (Ext. Ilium, between ant. & post. gluteal lines to lat. greater trochanter) Adducts & medially rotates. Sup. Gluteal N L5-S1.
Gluteus Minimus (Ext. Ilium, between ant. & inf. gluteal lines to Ant. great trochanter) Adducts & medially rotates thigh. Sup. Gluteal N L5-S1.
TFL (ASIS & ant. iliac crest to ITB) Adducts & medially rotates thigh. Sup. Gluteal N L5-S1.
Piriformis (Ant. Sacrum & Sacrotuberous lig. to Sup. Greater trochanter). Laterally rotates extended thigh, abducts flexed thigh. Ant. rami S1-S2.
Obturator Internus (Pelvic surface obturator membrane & surrounding bones to Med. greater trochanter, trochanteric fossa). Laterally rotates extended thigh, abducts flexed thigh. N to Obturator Internus L5-S1.
Sup. Gemelli (Ischial spine to Trochanteric Fossa). Laterally rotates extended thigh, abducts flexed thigh. N to Obturator Internus L5-S1.
Inf. Gemelli (Ischial tuberosity to Trochanteric fossa). Laterally rotates extended thigh, abducts flexed thigh. N to Quadratus Femoris L5-S1.
Quadratus Femoris (Lat. border Ischial tuberosity to quadrate tubercle on intertrochanteric crest. Laterally rotates thigh. N to Quadratus Femoris L5-S1.
- Anterior Compartment = Sartorius (Inf. to ASIS to upper Ant-Med. surface of Tib. Pes Anserinus)
Rectus Femoris (AIIS & iliac posrtion of acetabulum to patellar tendon)
Vastus Lateralis (Great Trochanter, Inter-Trochanteric line & Linea Aspera to Patella and Tib. tuberosity patella ligament)
Vastus Intermedius (Upper 2/3 of anterolateral Femur to Patella and Tib via patella lig)
Vastus Medialis (Anteromedial femur from intertrochanteric line , pectineal line and med. lip of linea aspera to patella)
(Occ. Iliacus – Iliac crest, fossa ala of sacrum & ant. SI lig to lesser trochanter. Psoas – Bodies T12-L5, discs and TP’s to lesser trochanter)
Femoral Nerve L2-4 (Illiacus Femoral L2-4, Psoas Ventral Rami L1-3)
Cutaneous Supply = Ant. Femoral Cutaneous N L2-3 and Lat. femoral Cutaneous N. L2-3
Femoral Artery
- Medial Compartment = Gracilis (Ant. margin lower ½ of symphasis pubis to upper anteromedial Tib. pes anserinus)
Adductors Magnus (A-Ischiopubic ramus H-Ischial tuberosity to A-Gluteal tuberosity, linea aspera & Med. supracondylar line)
Longus (Body of pubis to mid. 1/3 of linea aspera)
Brevis (Body & inf. ramus of pubis to pectineal line & proximal linea aspera)
(occ. Obturator Externus – edge of obturator foramen & membrane to trochanteric fossa & Pectineus – Sup. Pubic ramus to Pectineal line, inf. to lesser trochanter).
Obturator Nerve L2-4 (Obturator Externus Obturator L2-4, Pectineus Femoral L2-3)
Cutaneous Supply = Anterior Femoral Cutaneous N L2-3
Obturator Artery
- Posterior Compartment = Biceps Femoris (LH-Ischial tuberosity SH-Linea aspera & Lat. supracondylar line to Lat. head of Fib) Semimembranosus (Ischial tuberosity to post. med. tib.)
Semiteninosus (Iscial tuberosity to ant. med. sup. Tib. Pes anserinus) .
Sciatic Nerve (Tibial Part) L4-S3
Cutaneous Supply = Post. Femoral Cutaneous N S1-3
Inferior Gluteal Artery, Profunda Femoris and perforating arteries.
Femoral Triangle
Boundaries
Sup. = Inguinal lig.
Med. = Add. Longus
Lat. = Sartorius
Floor = Add. Longus & Iliopsoas
Roof = Fascia Lata
Contents
Femoral Nerve
Femoral Sheath - Femoral Artery, vein & canal (lymph vessels)
Hip
Multi-axial synovial joint (ball and socket).
Nerve supply = Femoral, Obturator & Sup. Gluteal Nerves
Blood supply = Cruciate anastomosis – Obturator artery, med. and lat. circumflex femoral arteries, sup. And inf. gluteal arteries.
Blood supply to head of femur = Acetabular branches of obturator and medial circumflex femoral arteries, ligament of head of femur (branch from obturator), med. and lat. femoral circumflex arteries.
Ligaments
Iliofemoral – ‘Y’ shaped. Ant. ASIS & Acetabular margin to Intertrochanteric line. Limits extension, adduction and medial rotation.
Pubofemoral – Inferomedial. Pubic part of acetabulum and Sup. Pubic ramus to Intertrochanteric line. Limits abduction and external rotation.
Ischiofemoral – Post. Ischial part of acetabulum to sup. Intertrochanteric line and neck of femur. Limits extension and adduction. Thin and weak.
Muscles
Gluteus Maximus (Ilium, post. gluteal line, dorsal sacrum & coccyx & sacrotuberous lig. to ITB & gluteal tuberosity) Extends & laterally rotates thigh. Inferior gluteal N L5-S2.
Gluteus Medius (Ext. Ilium, between ant. & post. gluteal lines to lat. greater trochanter) Adducts & medially rotates. Sup. Gluteal N L5-S1.
Gluteus Minimus (Ext. Ilium, between ant. & inf. gluteal lines to Ant. great trochanter) Adducts & medially rotates thigh. Sup. Gluteal N L5-S1.
TFL (ASIS & ant. iliac crest to ITB) Adducts & medially rotates thigh. Sup. Gluteal N L5-S1.
Piriformis (Ant. Sacrum & Sacrotuberous lig. to Sup. Greater trochanter). Laterally rotates extended thigh, abducts flexed thigh. Ant. rami S1-S2.
Obturator Internus (Pelvic surface obturator membrane & surrounding bones to Med. greater trochanter, trochanteric fossa). Laterally rotates extended thigh, abducts flexed thigh. N to Obturator Internus L5-S1.
Sup. Gemelli (Ischial spine to Trochanteric Fossa). Laterally rotates extended thigh, abducts flexed thigh. N to Obturator Internus L5-S1.
Inf. Gemelli (Ischial tuberosity to Trochanteric fossa). Laterally rotates extended thigh, abducts flexed thigh. N to Quadratus Femoris L5-S1.
Quadratus Femoris (Lat. border Ischial tuberosity to quadrate tubercle on intertrochanteric crest. Laterally rotates thigh. N to Quadratus Femoris L5-S1.